Depression Screening
Tool Kit
Working together
to improve the care and outcomes
of depression
in home healthcare patients
Introduction
Homecare clinicians are uniquely positioned to screen elderly patients for
depression. Depression is a major health problem for the elderly homecare
population. It is under diagnosed, under treated and can increase mortality
from other medical conditions. Depression is the number one risk factor for
suicide in late life. Importantly however, depression is treatable.
Screening for depression requires both direct questioning and observation.
The Outcome Assessment and Information Set (OASIS) that is required for
admission to a Medicare certified home care agency provides a framework
for screening.
The presence of depressed mood and/or diminished interest in activities that
the patient once found pleasurable is an indication for further evaluation.
Direct questions about thoughts of death and dying and suicide should be a
part of routine screening.
The following tools are intended to assist you in screening for depression in
older adults receiving homecare. They are designed for direct patient care
and use in the field.
© Copyright 2004
Weill Cornell Homecare Research Partnership
Weill Medical College of Cornell University
Tool Kit version 1.0 March 2005
Contents
1) Questions to Determine Presence of Depression
“Gateway Symptoms” (M0590 and M0600)
This section provides clinicians with a statement they can use with patients to
help ease the transition into a discussion on the topic of depression.
The purpose of the next series of questions is to assess depressed mood and
diminished interest in once pleasurable activities. Each is a key indicator that a person
may have a clinically significant depression and should be further evaluated.
2) Questions to Determine Suicide Risk (M0590)
The purpose of these questions is to elicit information about thoughts of
death and the risk of suicide.
While the first two questions are adequate to answer the OASIS items, additional
questions may be necessary to ask in some cases to further differentiate the level
of suicide risk. These questions are listed after the OASIS M0590 items.
3) Assessing Suicide Risk as a Spectrum
The purpose of this section is to assist the clinician in understanding that there is
a spectrum of thoughts of death that range between normal thoughts of death and
dying to suicidal thoughts that may indicate a more serious potential for harm.
4) Facts About Depression in the Elderly
The purpose of this patient education handout is to provide answers to patients
and caregivers regarding commonly asked questions about depression.
5) Commonly Used Antidepressants
The table provides information about commonly used antidepressant medication.
6) Special Considerations for Older Adults Treated
with Antidepressants
This tool provides general guidelines about the administration of antidepressants
to the elderly population. Some useful resources for nurses are also listed.
7) Nurse-Patient Interaction in the Context of Depression
The purpose of this section is to provide the clinician with suggestions on
how to interact with patients suffering from depression.
8) Mental Health Referral
The purpose of this tool is to assist the clinician in discussing the mental
health referral process with patients.
Tool Kit version 1.0 March 2005
Questions to Determine Presence of Depression
“Gateway” Symptoms (M0590 and M0600)
Introductory Statement to Patient
“Many times, people who need home care services go through a difficult
period of time. Some feel down or upset.”
Depressed Mood (M0590-1)
“How has your mood been in the past couple weeks?”
“Have you been feeling sad or depressed?”
If yes, ask each of the following questions:
“How much of the day do you feel this way?”
“How long have you felt this way?”
Diminished Interest in Most Activities (M0600-2)
“In the past few weeks, have you found yourself losing interest in activities
that you usually enjoy?”
If yes, ask each of the following questions:
“How much of the day do you feel this way?”
“How long have you felt this way?”
*Check off OASIS items if relevant symptoms have been present to any degree
during the past 2 weeks. Follow agency procedures for referral.
Tool Kit version 1.0 March 2005
Questions to Determine Suicide Risk
(M0590)
Recurrent thoughts of death (passive suicide ideation)
(M0590-4)
“In the past couple weeks, were things ever so bad that you had thoughts
that life is not worth living or that you’d be better off dead?”
Thoughts of suicide (active suicide ideation) (M0590-5)
“Have you had any thoughts about hurting yourself or suicide?”
If yes, ask each of the following questions:
“What have you been thinking of doing?”
“Do you have a plan for doing this?”
“Is there anything preventing you from harming yourself?”
“Do you feel you can resist thoughts about harming yourself?”
“Have you ever done anything to harm yourself?”
*Check off OASIS items if relevant symptoms have been present to any degree
during the past 2 weeks. Follow agency suicide risk protocol.
Tool Kit version 1.0 March 2005
Assessing Suicide Risk as a Spectrum*
Recurrent
thoughts of suicide
M0590-4
Thoughts of suicide
M0590-5
(active suicide ideation)
(passive suicide ideation)
Morbid preoccupation with
death; thoughts that life
is not worth living or that
would be better off dead
(eg, “I pray that God will
take me soon”).
Has not considered a
Method to harm self.
i sk
ld R ires
i
M equ
R ferral
Re
Is not preoccupied with
death; does not feel that
would be better off dead.
ow
Ri
Very Low Risk
Does not report a specific
detailed Plan or current
intention to harm self.
Demonstrates reasons for living
and good impulse control.
Mode
ra
Requ te Ris
Imm ires k
Refeediat
r ra e
l
R i sk
g h MH
Hi tact ian
n
c
Co lini Not
C
Do e Home
av
Le
May have occasional thoughts
about own mortality.
sk
Normal focus on end of life
issues due to advanced age,
medical illness, or dwindling
social networks.
Ver y
L
No
suicide
ideation
Has considered a Method
to harm self (eg, “I’ve
thought about taking all my
pills, but I would never do it”).
Reports a specific detailed
Plan and/or current
intention to harm self
(eg, “I’m planning to take all
my pills tomorrow morning
before my aide arrives”)
or does not have good
impulse control
(eg, “I may not be able to
stop myself from doing this”).
Specific
suicide
plan or
intent
Imminent suicide risk
*Always follow individual agency procedures for suicidal patients
Tool Kit version 1.0 March 2005
Facts About Depression in Older Adults
What Is Depression?
Depression is a medical illness. Depression is not an understandable reaction
to loss. Depression is not a customary response to the physical ailments
of growing old. Depression is not an expected part of the aging process.
Depression usually does not improve in response to different circumstances,
good news or the passing of time. Depression can last months or even years
if it is not treated.
Cardinal Symptoms:
• Depressed or sad mood
• Decreased interest or pleasure in activities
Other Symptoms:
• Significant changes in appetite or weight
• Sleep disturbances
• Restlessness or sluggishness
• Fatigue or loss of energy
• Lack of concentration or indecision
• Feelings of worthlessness or inappropriate guilt
• Thoughts of death or suicide
What Causes Depression?
Depression is caused by multiple factors ranging from genetic predisposition
to biological changes, to psychological trauma. Often depression results
when these factors interact with one another, although depression can also
occur without any obvious stressful event.
How Is Depression Treated?
Depression is treatable. Examples of appropriate treatment include medication
and/or psychotherapy. Equally important to treatment is monitoring and
follow-up over time. Appropriate treatment relieves symptoms for seventy
percent of older adults. If people receive proper treatment for depression they
will feel more energetic, hopeful, focused, and involved in daily activities.
Tool Kit version 1.0 March 2005
Commonly Used Antidepressants
Generic
Name
Brand
Name
Usual Daily
Dose Range
escitalopram
Lexapro
10–20 mg.
Nausea/constipation/diarrhea,
Dry mouth, Sleepiness, Insomnia,
Increased sweating, Headache,
Restlessness, Sexual dysfunction
citalopram1
Celexa
10–40 mg.
Nausea/constipation/diarrhea,
Dry mouth, Sleepiness,
Increased sweating, Sexual dysfunction
venlafaxine1
Effexor
75–225 mg.
Nausea/constipation/diarrhea,
Dry mouth, Sedation/fatigue,
Sleepiness, Headache, Increased
sweating, Increased blood pressure,
Sexual dysfunction
paroxetine1
Paxil
20–50 mg.
Nausea/constipation/diarrhea,
Dry mouth, Sleepiness, Insomnia,
Increased sweating, Headache,
Restlessness, Sexual dysfunction
fluoxetine1
Prozac
10–40 mg.
Nausea/constipation/diarrhea,
Dry mouth, Sleepiness, Insomnia,
Increased sweating, Headache,
Restlessness, Sexual dysfunction
sertraline1
Zoloft
50–150 mg.
Nausea/constipation/diarrhea,
Dry mouth, Sleepiness, Sedation/
fatigue, Insomnia, Increased
sweating, Headache, Restlessness,
Tremor, Sexual dysfunction
mirtazapine2 Remeron
15–45 mg.
Sedation/sleepiness, Weight/appetite
increase, Dizziness
bupropion
150–450 mg.
Headache, Dry mouth, Insomnia,
Nausea/constipation/diarrhea,
Anxiety/restlessness, Tremor
50–100 mg.
Sedation, Constipation (moderate),
Blurred vision, Orthostatic
Hypotension, Slowed cardiac
conduction, Increased sweating,
Tremor, Urinary retension
1
Wellbutrin
nortriptyline3 Pamelor
1
Common Side Effects
SSRI (selective serotonin reuptake inhibitor), 2 Heterocyclic, 3 Tricyclic
Tool Kit version 1.0 March 2005
Special Considerations for Older
Adults Treated with Antidepressants
Medical Comorbidity and Drug Interactions
SSRIs are used widely for the elderly because they have few contraindications
and risky side effects.
MAOI antidepressants should not be combined with antidepressants of any
other type. Drug interactions can have grave consequences.
Coumadin-SSRIs may modestly increase coumadin effects, so INRs should
be rechecked after starting these antidepressants.
Antidiuretic Hormone (ADH)- Rarely, inappropriate ADH secretions can occur
early in treatment, leading to hyponatremia. If confusion occurs, blood
electrolytes should be assessed.
Sensitivity to Side Effects
Elderly patients may be more sensitive to side effects, particularly constipation,
nausea and restlessness.
Dosage Considerations
Due to potential sensitivity of older persons, clinicians may start antidepressants
at low doses and increase them slowly (“start low & go slow”). HOWEVER,
the SSRI target dose is usually the same as that of younger patients.
Family Involvement
Family involvement is central to recovery from depression. The presence of
support has been linked to recovery from depression and family members
can help ensure medication adherence.
Resources:
www.psychceu.com/quickreference.doc.html
(Preston’s Psychopharmacology List)
Mosby’s Drug Guide for Nurses
Fifth Edition, Skidmore-Roth, Linda, RN. MSN, NP, Mosby, Mo. 2003
Psychiatric Medications for Older Adults: The Concise Guide
Salzman, Carl MD, The Guildford Press, 2001.
Tool Kit version 1.0 March 2005
Nurse-Patient Interaction
in the Context of Depression
REASSESS symptoms at each visit. If symptoms persist after a
month of treatment, contact physician.
REASSURE patients that depression is a medical illness,
and is not their fault.
SUPPORT patients by reassuring them that they can always call
on you or other health care providers for help and support.
ENCOURAGE patients to engage in activities that are pleasant
to them and that they are still able to do.
REMIND patients that depression is treatable, but it takes time.
REMAIN positive.
DO NOT… Ignore the depression. Track changes in depression
and adherence just like any other medical illness.
DO NOT…Allow patients to be hopeless. Hopelessness is a
symptom of depression; with proper treatment patients become
more hopeful about their health, their lives, and their future.
Tool Kit version 1.0 March 2005
Mental Health Referral
Referring a patient to a mental health specialist can be challenging. Sometimes
older adults with depression are reluctant to seek help. Perhaps the person is
not convinced that she or he needs help, or is skeptical that seeking help
will be of any consequence. The person may have previously had a negative
experience when seeking mental health care. Some older adults avoid seeking
help because they believe that having a mental health problem is stigmatizing
or shameful.
While there is no simple solution, often the best approach is to discuss mental
health treatment and referral in the context of other medical conditions.
Involving family members in the discussion can sometimes be helpful.
Advise patients that receiving mental health care is a necessity and as
important as taking care of a chronic physical condition like diabetes.
Inform patients that a mental health problem is not a character flaw but
rather a problem involving brain changes causing disturbances in thoughts,
emotions, behaviors, and somatic functions.
Here is a suggested way to introduce mental health referral
to your patients:
“It sounds like you have been going through a difficult time recently. I’d
like to have a nurse counselor (specialist) visit you to discuss some of these
issues. She/he will be able to spend more time talking with you. Is that
alright with you?”
“Mental Health Referral Tips: Encouraging a client or patient reluctant to seek
mental health services.” NY: Division of Geriatrics and Gerontology, Weill
Medical College of Cornell University.
Available at:
http://www.cornellcares.org/tips/tips3.html?name1=Mental+Health+
Referral+Tips&type1=2select
Tool Kit version 1.0 March 2005
Credits
Co-producers
• Martha L. Bruce, Ph.D., M.P.H.
• Ellen L. Brown, Ed.D, M.S., NP, RN
Writers
• Ellen L. Brown, Ed.D, M.S., NP, RN
• Patrick J. Raue, Ph.D.
• Martha L. Bruce, Ph.D., M.P.H.
• Thomas F. Sheeran, Ph.D., M.E.
Director/Contributing Psychiatrist
• Barnett S. Meyers, M.D.
Development Team
• Denise C. Fyffe, Ph.D.
• Amy E. Mlodzianowski, M.S., LMSW
Mental Health Nursing Consultant
• Judith C. Pomerantz, M.S., APRN-BC
Actors
• Nurse: Susan J. Bodell
• Mr. James: Arthur French
• Mrs. Lee: Margaret Wright
• Narrator: Katie Karlovitz
Video Production and Graphic Design
• Center for Biomedical Communications, Audio Visual Services (a division of Columbia
University Health Services at Columbia University Medical Center)
Funding Source:
• National Institutes of Mental Health (R24MH64608; PI: Martha L. Bruce, Ph.D., M.P.H.)
With additional funding from:
• K02 MH01634, K01 MH066942, Weill Cornell Center for Aging Research and Clinical
Care, and the Institute of Geriatric Psychiatry, Weill Medical College of Cornell University
• Developed as part of the Weill Cornell Homecare Research Partnership, with special
thanks to the staff of Dominican Sisters Family Health Service (DSFHS), Visiting Nurse
Association of Hudson Valley (VNAHV), and Visiting Nurse Services in Westchester
(VNSW) for their contributions and ongoing collaboration.
Cover of the DSM-IV-TR: Reprinted with the permission from the Diagnostic and
Statistical Manual Disorders, Text Revision, Copyright, 2000 American Psychiatric Association
© Copyright 2004
Weill Cornell Homecare Research Partnership
Weill Medical College of Cornell University
Tool Kit version 1.0 March 2005